Citation Nr: 0824054
Decision Date: 07/18/08 Archive Date: 07/30/08
DOCKET NO. 06-17 659A ) DATE
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)
On appeal from the
Department of Veterans Affairs Medical Center in Palo Alto,
California
THE ISSUE
1. Entitlement to reimbursement for medical expenses for
treatment provided by San Mateo County Medical Center on July
1, 2004.
2. Entitlement to reimbursement for expenses incurred for
travel by ambulance provided by American Medical Response to
San Mateo County Medical Center on July 1, 2004.
REPRESENTATION
Appellant represented by: Melissa A. Rodgers, Attorney
ATTORNEY FOR THE BOARD
L. B. Cryan, Counsel
INTRODUCTION
The veteran had active service from April 1979 to April 1982.
This case is before the Board of Veterans' Appeals (Board) on
appeal from a September 2005 administrative decision by the
Department of Veterans Affairs Medical Center (VAMC) in Palo
Alto, California, that denied the veteran's claims for
reimbursement for unauthorized medical expenses for ambulance
transport to, and treatment provided by, San Mateo County
Medical Center on July 1, 2004.
The appeal is REMANDED to the RO via the Appeals Management
Center (AMC), in Washington, DC. VA will notify the
appellant if further action is required.
REMAND
The veteran seeks reimbursement under the Veterans Millennium
Health care and Benefits Act (Millennium Bill) codified at 38
U.S.C.A. § 1725 and 38 C.F.R. §§ 17.1000-1008, for
unauthorized medical expenses associated with treatment
provided by San Mateo County Medical Center on July 1, 2004,
and for transportation thereto provided by the American
Medical Response (AMR).
To be eligible for reimbursement under this authority the
veteran has to satisfy all of the following conditions:
(a) The emergency services were provided in a hospital
emergency department or a similar facility held out as
providing emergency care to the public; (b) The claim for
payment or reimbursement for the initial evaluation and
treatment is for a condition of such a nature that a prudent
layperson would have reasonably expected that delay in
seeking immediate medical attention would have been hazardous
to life or health (this standard would be met if there were
an emergency medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that
a prudent layperson who possesses an average knowledge of
health and medicine could reasonably expect the absence of
immediate medical attention to result in placing the health
of the individual in serious jeopardy, serious impairment to
bodily functions, or serious dysfunction of any bodily organ
or part); (c) A VA or other Federal facility/provider was not
feasibly available and an attempt to use them before hand
would not have been considered reasonable by a prudent
layperson (as an example, these conditions would be met by
evidence establishing that a veteran was brought to a
hospital in an ambulance and the ambulance personnel
determined that the nearest available appropriate level of
care was at a non-VA medical center); (d) The claim for
payment or reimbursement for any medical care beyond the
initial emergency evaluation and treatment is for a continued
medical emergency of such a nature that the veteran could not
have been safely transferred to a VA or other Federal
facility; (e) At the time the emergency treatment was
furnished, the veteran was enrolled in the VA health care
system and had received medical services under authority of
38 U.S.C. Chapter 17 within the 24-month period preceding the
furnishing of such emergency treatment; (f) The veteran is
financially liable to the provider of that emergency
treatment for that treatment; (g) The veteran has no coverage
under a health-plan contract for payment or reimbursement, in
whole or in part, for the emergency treatment (this condition
cannot be met if the veteran has coverage under a health-plan
contract but payment is barred because of a failure by the
veteran or provider to comply with the provisions of that
health-plan contract, e.g., failure to submit a bill or
medical records within specified time limits, or failure to
exhaust appeals of the denial of payment); (h) If the
condition for which the emergency treatment was furnished was
caused by an accident or work-related injury, the claimant
has exhausted without success all claims and remedies
reasonably available to the veteran or provider against a
third party for payment of such treatment; and the veteran
has no contractual or legal recourse against a third party
that could reasonably be pursued for the purpose of
extinguishing, in whole or in part, the veteran's liability
to the provider; (i) The veteran is not eligible for
reimbursement under 38 U.S.C. 1728 for the emergency
treatment provided (38 U.S.C. § 1728 authorizes VA payment or
reimbursement for emergency treatment to a limited group of
veterans, primarily those who receive emergency treatment for
a service-connected disability). 38 C.F.R. § 17.1002.
According to the veteran, his medical condition was emergent
and a VA facility was not feasibly available during his
period of treatment because his seizures left him in an
altered state, unable to adequately communicate to the AMR
providers that he needed to be transported to a VA facility.
The veteran does not have any health insurance. The current
record suggests that the veteran suffered from a seizure at a
friend's house, which left him in an altered state. The
veteran maintains that he does not recall what happened to
him during that time period. He was transported to San Mateo
County Medical Center, the closest facility, and remained
there until stabilized.
What is unclear is whether the veteran had been previously
admitted to a VA facility on June 29, 2004, and then
subsequently left that facility against medical advice. A
portion of a June 29, 2004 VA medical record shows that the
veteran was admitted after being seen because of a grand mal
seizure. That record is incomplete, however, and there are
no other VA medical records associated with the claims file.
Nevertheless, a "Clinical Review and Assessment Form" dated
September 29, 2005 indicates that the veteran left a VA
facility on June 30, 2004 "AMA" (against medical advice).
There are no actual hospital records in the file documenting
treatment on that day or documenting that the veteran left
AMA. Also, it is unclear as to whether the veteran was
oriented at the time he was transported on July 1, 2004; and,
finally, it appears that the veteran may have been
transported by ambulance twice on July 1, 2004. There is a
July 1, 2004 notation on a AMR record indicating that the
veteran was found in the front yard of someone's home about 1
block away from the hospital after walking out of the San
Mateo County Medical Center because the "doctor was a
quack." Other AMR records from the same day note that the
veteran was oriented.
The VAMC denied the veteran's claim for reimbursement of
medical expenses incurred on July 1, 2004 because VA
facilities were feasibly available. Given the lack of a
complete medical record in this case, the Board is unable to
determine whether VA facilities were feasibly available on
July 1, 2004.
Accordingly, the case is REMANDED for the following action:
1. Obtain copies of all of the veteran's
VA medical records from the Palo, Alto,
California VA Medical Center dated from
June 1, 2004 to July 30, 2004. All copies
obtained should be associated with the
veteran's claims folder.
2. With appropriate authorization from
the veteran, obtain and associate with the
claims file copies of all of the veteran's
medical records from the San Mateo County
Medical Center from June 1, 2004 to July
30, 2004.
3. If, and only if, the medical record
reflects that the veteran did not leave
the VAMC on June 30, 2004 against medical
advice, obtain a specialist's opinion as
to whether the veteran's condition on July
1, 2004 rendered him so disoriented as to
be unable to communicate to the ambulance
crew or the San Mateo County Medical
Center that he had no insurance and needed
to receive care at the nearest VAMC.
4. If, and only if, the medical record
reflects that the veteran did leave the
VAMC against medical advice on June 30,
2004, obtain a specialist's opinion as to
whether the veteran's medical condition on
June 30, 2004 is related to the medical
condition for which treatment was rendered
on July 1, 2004.
5. Following completion of the
development requested, readjudicate the
veteran's claims. If any benefit sought
on appeal remains denied, the veteran and
his representative should be provided with
a supplemental statement of the case
(SSOC), and an appropriate period of time
allowed for response.
The appellant has the right to submit additional evidence and
argument on the matters the Board has remanded.
Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment. The law
requires that all claims that are remanded by the Board of
Veterans' Appeals or by the United States Court of Appeals
for Veterans Claims for additional development or other
appropriate action must be handled in an expeditious manner.
See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007).
_________________________________________________
RONALD W. SCHOLZ
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Appeals for Veterans Claims. This remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal.
38 C.F.R. § 20.1100(b) (2007).